Getting serious about a single payer system [Commentary]

James F. Burdick

A single payer system — where the government pays for health costs — is now recognized by many in the U.S. as the best solution for our health care problems. It was taken "off the table" in 2009 by Sen. Max Baucus, A Montana Democrat who reportedly received more money from the pharmaceutical and health insurance industries than any other Congressman. But now the flood of single payer advocacy cannot be turned off by vested business interests. It is time to progress from the stereotype of single payer to having a serious discussion about it.

Ironically, even after its recent success in covering millions more Americans, the problems with the Affordable Care Act serve to illuminate the advantages of single payer. The public, although confused by the divisive rhetoric around health care reform, is coming to realize that the complexity of the law and the pursuit of insurance company profits are major problems for the ACA. Back in 2009, a majority of Americans favored a single payer-like system. The country may now lose patience with the protracted process of ACA implementation, with Republicans yapping at its heels, until 2020 when the final provision closing the Medicare prescription drug doughnut hole fully kicks in.

The 30-page H.R. 676, the single payer bill of Rep. John Conyers Jr., a Michigan Democrat, shows how simple it is to cover everyone. It provides savings through quality care — including protection from harmful overuse and efficient, timely management of chronic disease — as well as savings through national monopsony buying power and freedom from insurance business profits.

But if this bill, regularly reintroduced since 2003, is now to be taken seriously, it needs improvement. Most importantly, the proposed federal board governing both payment and care decisions lacks clinical authority and is too politicized. Instead, doctors must be granted, and must accept, responsibility for a national, private, transparent, interprofessional and data-driven mechanism to define quality options for care choices. This will free us from the snarl of various quality guidelines and protect our patients from irrelevant insurance and government interference while providing authoritative relief from over-utilization. This key improvement in the bill is also needed because coverage decisions must be removed from states, as proven by their politicized Medicaid problems.

Most politicians and health policy experts with national reputations remain silent. Some may have too great a stake in the ACA to join in the single payer adventure right away. But the country did just pass this valuable law. Even recognizing the tight political maneuvering required, this attests that the political potential for major change to our health care system is there. Luminaries who have asserted the wisdom of single payer include political commentator Bill Maher, former U.S. Secretary of State Colin Powell, Nobel-prize winning economist Paul Krugman, Sen. Bernie Sanders of the Vermont Progressive Party and former U.S. Labor Secretary Robert Reich. With even conservative columnist Ross Douthat alluding to the unspeakable in the April 5th New York Times "(ahem, single payer)" and a number of states trying to establish it on their own, supporting single payer nationally no longer appears out of reach.

There is considerable professional activity already underway with efforts that will fit the needs of a successful single payer system. These include defending against overuse by the "Choosing Care Wisely" and "Avoiding Avoidable Care" initiatives, plus the National Surgical Quality Improvement Program and the nationally successful program to abolish central line infections spearheaded by Johns Hopkins Hospital's Dr. Peter Pronovost, which are all examples of doctors and hospitals working together to share data and improve care. Placing the patient first through use of medical homes and Affordable Care Organizations is often led by doctors. In an attempt to rule out Wall Street domination, doctors and hospitals are establishing insurance plans for their patients on their own. These patient-centered programs will be more successful in a single payer context. For coordination of all of these care advisories, the American College of Physicians has recommended a national doctors board to determine core benefits.

The paper by Drs. Ray Drasga and Lawrence Einhorn, both of Indiana, in the Journal of Oncology Practice from January showing how their cancer patients would benefit from single payer is a beacon for all of medicine. Other prominent doctors recently supporting it include Dr. Nancy Snyderman of NBC and Dr. James Mitchison of The American College of Emergency Physicians. The Physicians for a National Health Program promoting single payer is now 18,000 members strong. American nurses strongly support single payer. Polls confirm that individual doctors support a national plan to provide health care to all Americans, as do the American College of Physicians and the American Medical Association.

This medical advocacy will reassure the public. Soon candidates who wish to be seen as working for all Americans will support single payer, or they will have some explaining to do.

Dr. James Burdick is Professor of Surgery at Johns Hopkins University School of Medicine. He had a career as a transplant surgeon and served in the Department of Health and Human Services as director of the Division of Transplantation. He is writing a book detailing his plan for patient-centered health reform. His email is jburdic1@jhmi.edu.